Treatment-Related Complications of Systemic Therapy and Radiotherapy

Neutrophil Depletion Reduced the Relative Abundance of Unsaturated Long-Chain Fatty Acid Synthesis Microbiota and Intestinal Lipid Absorption

As immune cells, neutrophils serve as the first line of defense against infections; however, the mechanism by which neutrophils regulate lipid metabolism is unknown. The neutrophil depletion group was treated with 100 μg InVivoMAb anti-mouse Ly6G 6 times, whereas the control group mice were intraperitoneally injected with the same quantity of InVivoMAb rat IgG2a. Body fat content, triglycerides (TGs), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C) in the jejunum and ileum, as well as 9 long-chain fatty acids (LCFAs) in the intestinal contents were significantly decreased. Furthermore, genes involved in the absorption of lipids in each segment of the intestine also showed decreased expression. Neutrophil-depletion and control models were administered 25 μCi of 3H-cholesterol by gavage. The distribution of 3H cholesterol in the intestinal segment, heart, liver, serum, and feces was not altered by anti-Ly6G antibodies. Metagenomics was applied to investigate uncultured microorganisms in the intestinal contents to identify bacteria containing lipid metabolism genes. At the species level, 12 bacteria were involved in unsaturated LCFA synthesis, among which 2 increased and 10 decreased. The overall relative abundance of these bacteria decreased from 3.102% to 0.734%. Many genes involved in lipid metabolism were also reduced as a result, such as fatty acid synthase and peroxisome proliferator-activated receptor γ. In conclusion, neutrophil depletion does not affect intestinal lipid absorption in the diet but leads to a decrease in the overall relative abundance of gut bacteria involved in unsaturated LCFA synthesis. Consequently, intestinal lipid synthesis and absorption are reduced.

Patterns in Symptoms Preceding Acute Care in Patients With Cancer

Importance

Patients with cancer frequently experience unplanned acute care with emergency department visits and hospitalization due to disease or treatment complications, which impacts outcomes, quality of life, and health care costs. There remains a knowledge gap in understanding patterns of symptoms that precede acute care events. Natural language processing (NLP) may enable greater understanding of the symptoms and identify differences across patient and cancer characteristics.

Objective

To characterize symptoms preceding acute care in patients with cancer and quantify differences in symptom documentation across sociodemographic and cancer histologic subgroups.

Design, Setting, and Participants

A cohort study in a single tertiary-care institution, including all acute care (emergency department and hospitalization) encounters for patients aged 18 years or older with a primary cancer diagnosis identified between January 1, 2013, and December 31, 2023.

Main Outcomes and Measures

Natural language processing was used to identify routine clinical documentation to characterize symptoms documented in the 30 days preceding acute care. Logistic regression analyses was used to examine the possible association between sex, age, race and ethnicity, insurance coverage, cancer histologic characteristics, and reported symptoms.

Results

Overall, 28 708 patients with cancer had 70 606 acute care visits with 854 830 associated preceding documented symptoms. Median age was 61 (IQR, 48-70) years. Men (37 861 encounters [53.62%]) and patients of White race (39 989 encounters [56.64%]) accounted for most acute care encounters. Pain (7.54% of documented symptoms), nausea (6.74%), and vomiting (5.79%) were the most frequently documented symptoms. Acute care encounters with patients who were female (adjusted odds ratio [AOR], 1.14; 95% CI, 1.10-1.18; P < .001), Asian (AOR, 1.22; 1.17-1.28; P < .001), Black (AOR, 1.17; 95% CI, 1.10-1.25; P < .001), American Indian or Alaska Native (AOR, 1.21; 95% CI, 1.01-1.44; P = .04), or Medicaid-insured (AOR, 1.10; 95% CI, 1.05-1.14; P < .001) were associated with a high documented symptom burden (>10 unique symptoms) preceding acute care visits. Patients aged 65 years or older (AOR, 0.96; 95% CI, 0.92-1.00; P = .04) or uninsured (AOR, 0.58; 95% CI, 0.45-0.76; P < .001) were less likely to have a high symptom burden documented before acute care events.

Conclusions and Relevance

The findings of this study highlight common symptoms preceding acute care as well as the need for further research on interventions to reduce patient burden, improve quality of life, and reduce the use of acute care in patients with cancer.

Revolutionizing oncology care: pioneering AI models to foresee pneumonia-related mortality

BACKGROUND

Pneumonia is a leading cause of morbidity and mortality among patients with cancer, and survival time is a primary concern. Despite their importance, there is a dearth of accurate predictive models in clinical settings. This study aimed to determine the incidence of pneumonia as a cause of death in patients with cancer, analyze trends and risk factors associated with mortality, and develop corresponding predictive models.

METHODS

We included 26,938 cancer patients in the United States who died from pneumonia between 1973 and 2020, as identified through the Surveillance, Epidemiology, and End Results (SEER) program. Cox regression analysis was used to ascertain the prognostic factors for patients with cancer. The CatBoost model was constructed to predict survival rates via a cross-validation method. Additionally, our model was validated using a cohort of cancer patients from our institution and deployed via a free-access software interface.

RESULTS

The most common cancers resulting in pneumonia-related deaths were prostate (n=7300) and breast (n=5107) cancers, followed by lung and bronchus (n=2839) cancers. The top four cancer systems were digestive (n=5882), endocrine (n=5242), urologic (n=5198), and hematologic (n=3104) systems. The majority of patients were over 70 years old (57.7%), and 54.4% were male. Our CatBoost model demonstrated high precision and accuracy, outperforming other models in predicting the survival of cancer patients with pneumonia (6-month AUC=0.8384,1-year AUC=0.8255,2-year AUC=0.8039, and 3-year AUC=0.7939). The models also revealed robust performance in an external independent dataset (6-month AUC=0.689; 1-year AUC=0.838; 2-year AUC=0.834; and 3-year AUC=0.828). According to the SHAP explanation analysis, the top five factors affecting prognosis were surgery, stage, age, site, and sex; surgery was the most significant factor in both the short-term (6 months and 1 year) and long-term (2 years and 3 years) prognostic models; surgery improved patient prognosis for digestive and endocrine tumor sites with respect to both short- and long-term outcomes but decreased the prognosis of urological and hematologic tumors.

CONCLUSION

Pneumonia remains a major cause of illness and death in patients with cancer, particularly those with digestive system cancers. The early identification of risk factors and timely intervention may help mitigate the negative impact on patients' quality of life and prognosis, improve outcomes, and prevent early deaths caused by infections, which are often preventable.

Safety of Naldemedine for Opioid-Induced Constipation - A Systematic Review and Meta-Analysis

Naldemedine is a peripheral acting µ-opioid receptor antagonist approved by the Food and Drug Administration to treat opioid-induced constipation. Concerns about side effects like opioid withdrawal prevent its widespread use, especially for cancer patients. We performed this systematic review and meta-analysis to evaluate existing safety data of naldemedine treating opioid-induced constipation following the PRISMA guidelines. We searched PubMed and the Cochrane Library on April 16th 2024 to identify studies evaluating naldemedine treatment among patients with opioid-induced constipation. Our analysis found no differences between groups comparing naldemedine therapy with placebo-control for treatment-emergent adverse events (OR = 1.06; 95%-CI: 0.91-1.24), serious adverse events (OR = 1.02; 95%-CI: 0.76-1.38). We found no increased risk for opioid withdrawal, while an increased risk for gastrointestinal disorders (OR = 2.08; 95%-CI: 1.72-2.51), particularly higher incidences of diarrhea (OR = 2.44; 95%-CI: 1.81-3.29) and abdominal pain (OR = 3.31; 95%-CI: 2.16-5.06) were found. In the cancer subgroup, treatment-emergent and serious adverse events were more frequent. However, no increased risk for opioid withdrawal was observed. This analysis confirms naldemedine's overall safety in treating opioid-induced constipation, with manageable gastrointestinal side effects. However, the higher adverse events in cancer patients require further investigation to ensure safe use in this population.

Epidemiologic trends and characteristics of cancer-related emergency department visits of older patients living with cancer in South Korea

We aimed to investigate the demographic characteristics, common chief complaints, and diagnosis of geriatric cancer-related emergency department (ED) visits and trends of ED outcomes. This retrospective observational study included all ED visits in South Korea between 2016 and 2020. The study population was older people ≥ 65 years living with cancer who visited ED with cancer-related problems. The demographics, common diagnoses, and ED outcomes were investigated. A multivariate logistic regression analysis was conducted to investigate factors associated with mortality. Geriatric cancer-related ED (GCED) visits were 746,416 cases over 5 years. The proportion of older adults among cancer-related ED visits increased from 50.1% in 2016 to 55.3% in 2020. The proportion of the "oldest old" (≥ 85 years) increased from 9.6 to 12.1%. For GCED, the ward admission rate after ED treatment was 60.2% and in-hospital mortality rate was 11.8%. Both of these increased with age group ("young old" (65-74), "middle old" (75-84), and "oldest old" (≥ 85 years) groups admission rates: 56.1%, 62.8%, and 68.0%; and mortality rates: 10.0%, 12.7%, and 15.7%, respectively). The most common diagnosis was pneumonia (4.9%). Old age and ambulance use were also associated with mortality. Older adults account for more than half of cancer-related ED visits, and their number is increasing every year. GCED visits are associated with high hospitalization and mortality, especially among the oldest old. It is important to prepare for a rise in GCED visits is necessary.

Emerging burden of post-cancer therapy complications on unplanned hospitalisation and costs among Australian cancer patients: a retrospective cohort study over 14 years

Cancer treatment using systemic therapy and radiotherapy may cause post-therapy complications, resulting in increased unplanned hospitalisation. The evidence on such complications, their impact on unplanned hospitalisations, and associated costs is scant in Australia. We aimed to estimate the prevalence of post-therapy complications, evaluate their impact on unplanned hospitalisation, length of stay (LOS) and investigate the associated medical costs. A retrospective cohort study was conducted among 8,633 cancer patients (1.03 million emergency hospital admissions) in Victoria, Australia from July 2006 to June 2020, from the Australian healthcare system perspective. Multivariate generalised linear regression models were employed to estimate the adjusted association between post-therapy complications and clinical characteristics with hospital LOS and associated hospitalisation medical costs. Approximately 52% of patients were male with an average patient age of 59.9 years. Annually, post-therapy complications leading to unplanned hospitalisations increased by 7.25%, outpacing the growth in overall hospitalisation admissions, which was 5.66% for overall hospitalisation admissions. A significant proportion of patients (71%) experienced multiple complications, with the most common being anemia (26%), sepsis (15%), nausea and vomiting (14%), and neutropenia (11%). Patients undergoing combined systemic and radiotherapy exhibited higher odds of post-therapy complications (OR = 8.24, 95%CI: 7.48 to 9.08) compared with those who only received systemic therapy. Mean hospital stay among patients who experienced post-therapy complications was 2.23 days per admission (360 days per patient), an extra 1.72 days per admission [95%CI: 1.68 to 1.76; 354 days per patient, 95%CI: 336 to 371 days] longer than patients without complications (0.51 days per admission and 6.48 days per patients). Overall, per-admission medical hospitalisation costs among patients with post-therapy complications were $8,791 higher than for patients who did not experience complications ($11,418 vs. $2,627 per admission, 95%CI: $8,685 to $8,897). Per-patient costs for unplanned hospitalisation due to post-therapy complications were significantly $1.82 million higher among patients than those without complications ($1.86 million vs. $33,599 per patient, 95%CI: $1.71 million to $1.94 million). The cost and hospitalisation stay (in days) varied by the type of therapy and cancer type. The study results indicate that post-therapy complications in cancer patients varied by the type of cancer and increased over the study period, leading to longer unplanned hospital stays and higher hospitalisation medical costs. The results highlight the need for better-customized treatment delivery strategies to address this burden and optimise resources in cancer care.

Incidence, characteristics, and clinical impact of serious adverse events in patients with breast cancer receiving antineoplastic treatment in the ambulatory setting

Patients with breast cancer experience various types of adverse events (AEs) during their treatment journey. We aimed to evaluate the incidence, characteristics, and impact of serious AEs in breast cancer patients receiving antineoplastic treatment in the ambulatory setting. A 4-month prospective observational study that included patients with breast cancer treated in the chemotherapy infusion clinics. Patients were assessed for serious AEs, defined as any AE that resulted in a visit to the emergency department (ED) with or without hospital admission, or required any clinical intervention, which were considered as the addition of supportive medications or modifications to the treatment protocol. Characteristics of the patients and antineoplastic regimens as well as the type of AEs were recorded. During the study period, 1168 patients received 2547 cycles. The mean age was 50 ± 11.6 (SD) years and patients had received a median (IQR) of 3 (1-5) treatment cycles prior to enrollment. Among the study cohort, 465 patients(40%) developed at least one serious AE. A total of 660 (26%) cycles were associated with 757 AEs, which required ED visits, addition of supportive medications, and modifications to the treatment protocol in 58%, 29%, and 17% of the cycles, respectively. Most common AEs were musculoskeletal (n = 132, 17%) and gastrointestinal (n = 125, 16.5%). Taxane-based regimens were associated with the most AEs (n = 286, 38%). In a cohort of patients with breast cancer treated in the ambulatory setting, 4 out of 10 patients developed at least one serious AE during the study period. Future research should identify measures to reduce the incidence and severity of such complications.

Risk Factors for Unplanned Emergency Department Visits in Patients with Nasopharyngeal Carcinoma During Radiotherapy

Background/Objectives: Nasopharyngeal carcinoma (NPC) is commonly treated with radiotherapy (RT) or concurrent chemoradiotherapy (CCRT). However, unplanned emergency department (ED) visits during treatment can disrupt therapy and impact patient outcomes. This study aims to identify the risk factors associated with unplanned ED visits in patients with NPC receiving RT or CCRT. Methods: We retrospectively analyzed 2111 patients with NPC treated between 2001 and 2019 at Chang Gung Memorial Hospital. Patients were categorized based on whether they experienced an unplanned ED visit during or up to three months post-treatment. Demographic and clinical variables were compared using the Chi-squared test, and survival outcomes were assessed using Kaplan-Meier analysis. Results: Among the cohort, 573 patients (27.2%) experienced at least 1 unplanned ED visit. Risk factors for unplanned ED visits included older age (p < 0.001), hypertension (p < 0.001), higher Charlson Comorbidity Index (p = 0.001), and advanced clinical stage (T stage, p = 0.0046; N stage, p = 0.0034; M stage, p = 0.0008). No significant difference in ED visit rates was observed between RT alone and CCRT groups. Conclusions: Unplanned ED visits were common during NPC treatment, with risk factors primarily related to patient age, comorbidities, and disease stage. Identifying high-risk patients may enable interventions to reduce ED visits, improve survival outcomes, and alleviate healthcare costs.

Prediction of 90-day mortality risk after unplanned emergency department visits of advanced stage cancer patients

PURPOSE

Cancer represents the leading cause of mortality in high-income countries. In the last years, the rate of emergency department (ED) visits by cancer patients has increased 5.5-fold. These ED visits impose a significant economic burden and may indicate the progression of the oncologic disease. The goal of this retrospective study was to identify patient-derived risk factors, especially focusing on serum albumin and body mass index (BMI) for 90-day mortality following unplanned ED visits by cancer patients.

METHODS

A retrospective chart review of all patients with an ICD-10 diagnosis for cancer undergoing palliative treatment presenting at the ED between 2016 and 2018 at the General Hospital of Vienna was performed. Laboratory values, emergency severity index (ESI), and BMI were collected at the ED presentation. 90-day mortality (90MM) was calculated from the ED presentation.

RESULTS

A total of 448 cancer patients were included. Lung cancer (19.2%) and pancreaticobiliary cancer (15.6%) were the most frequent diagnoses. The main reasons for ED visits were pain (20.5%) and fever (17.4%). Sixty-nine percent of patients had to be admitted and 17.5% of patients died during hospitalization. 90MM was highest for patients with low albumin (< 35 g/L vs. > 35 g/L: 60.4% vs. 31.4%; p < .0001). When incorporating albumin levels and BMI, patients with both values below the cutoff had the highest risk for death (HR 4.01, 95% CI 2.30-7.02).

CONCLUSION

Cancer patients face a high risk for hospitalization when presenting at the ED. The 90MM rate is highest in patients with low BMI and albumin levels. This highlights an especially vulnerable cohort of cancer patients for whom supportive care and palliative care have to be optimized.

Systemic therapy and radiotherapy related complications and subsequent hospitalisation rates: a systematic review

BACKGROUND

Hospitalisation  resulting from complications of systemic therapy and radiotherapy places a substantial burden on the patient, society, and healthcare system. To formulate preventive strategies and enhance patient care, it is crucial to understand the connection between complications and the need for subsequent hospitalisation. This review aimed to assess the existing literature on complications related to systemic and radiotherapy treatments for cancer, and their impact on hospitalisation rates.

METHODS

Data was obtained via electronic searches of the PubMed, Scopus, Embase and Google Scholar online databases to select relevant peer-reviewed papers for studies published between January 1, 2000, and August 30, 2023. We searched for a combination of keywords in electronic databases and used a standard form to extract data from each article. The initial specific interest was to categorise the articles based on the aspects explored, especially complications due to systemic and radiotherapy and their impact on hospitalisation. The second interest was to examine the methodological quality of studies to accommodate the inherent heterogeneity. The study protocol was registered with PROSPERO (CRD42023462532).

FINDINGS

Of 3289 potential articles 25 were selected for inclusion with ~ 34 million patients. Among the selected articles 21 were cohort studies, three were randomised control trials (RCTs) and one study was cross-sectional design. Out of the 25 studies, 6 studies reported ≥ 10 complications, while 7 studies reported complications ranging from 6 to 10. Three studies reported on a single complication, 5 studies reported at least two complications but fewer than six, and 3 studies reported higher numbers of complications (≥ 15) compared with other selected studies. Among the reported complications, neutropenia, cardiac complications, vomiting, fever, and kidney/renal injury were the top-most. The severity of post-therapy complications varied depending on the type of therapy. Studies indicated that patients treated with combination therapy had a higher number of post-therapy complications across the selected studies. Twenty studies (80%) reported the overall rate of hospitalisation among patients. Seven studies revealed a hospitalisation rate of over 50% among cancer patients who had at least one complication. Furthermore, two studies reported a high hospitalisation rate (> 90%) attributed to therapy-repeated complications.

CONCLUSION

The burden of post-therapy complications is emerging across treatment modalities. Combination therapy is particularly associated with a higher number of post-therapy complications. Ongoing research and treatment strategies are imperative for mitigating the complications of cancer therapies and treatment procedures. Concurrently, healthcare reforms and enhancement are essential to address the elevated hospitalisation rates resulting from treatment-related complications in cancer patients.

Piperlongumine and its derivatives against cancer: A recent update and future prospective

Piperlongumine, or piplartine (PL), is a bioactive alkaloid isolated from Piper longum L. and a potent phytoconstituent in Indian Ayurveda and traditional Chinese medicine with a lot of therapeutic benefits. Apart from all of its biological activities, it demonstrates multimodal anticancer activity by targeting various cancer-associated pathways and being less toxic to normal cells. According to their structure-activity relationship (SAR), the trimethylphenyl ring (cinnamoyl core) and 5,6-dihydropyridin-2-(1H)-one (piperdine core) are responsible for the potent anticancer activity. However, it has poor intrinsic properties (low aqueous solubility, poor bioavailability, etc.). As a result, pharmaceutical researchers have been trying to optimise or modify the structure of PL to improve the drug-likeness profiles. The present review selected 26 eligible research articles on PL derivatives published between 2012 and 2023, followed by the preferred reporting items for systematic reviews and meta-analyses (PRISMA) format. We have thoroughly summarised the anticancer potency, mode of action, SAR and drug chemistry of the proposed PL-derivatives against different cancer cells. Overall, SAR analyses with respect to anticancer potency and drug-ability revealed that substitution of methoxy to hydroxyl, attachment of ligustrazine and 4-hydroxycoumarin heterocyclic rings in place of phenyl rings, and attachment of heterocyclic rings like indole at the C7-C8 olefin position in native PL can help to improve anticancer activity, aqueous solubility, cell permeability, and bioavailability, making them potential leads. Hopefully, the large-scale collection and critical drug-chemistry analyses will be helpful to pharmaceutical and academic researchers in developing potential, less-toxic and cost-effective PL-derivatives that can be used against different cancers.

Photodynamic therapy mediated by methylene blue-loaded PEG accelerates skin mouse wound healing: an immune response

PURPOSE

Conventional approaches for enhancing wound healing may not always yield satisfactory results. Instead, we test the effectiveness of a newly developed photodynamic therapy (PDT) that uses methylene blue (MB) loaded with polyethylene glycol (PEG) (MB-PEG) hydrogel to accelerate wound healing process in mice.

METHODS

A dorsal skin incision with 6 mm punch which topically subjected to MB-PEG hydrogel and a low-level laser light of red light to assess the regeneration process of wounded skin. A total of 63 adult male CD1 mice divided into normal group (no treatment) and other wound groups received different treatments of laser (650 ± 5 nm and power intensity of 180 mW/cm2), MB-PEG, or PDT (MB-PEG followed by laser). The wound healing parameters were investigated by histological examination of the skin and measuring of proinflammatory cytokines at the early stage (48 h) and a late one on day 21.

RESULTS

at 48 h, the score of tissue granulation, inflammation, and angiogenesis process were markedly improved in wounded groups that received MB + PEG combined with laser compared to the group treated with laser alone. On day 21, a significant improvement of the inflammation was detected in the group treated with MB + PEG plus laser compared to the other groups. At 48 h, the upregulated serum levels of tumor necrosis factor (TNF)-α and interleukin (IL)-1β in the wound group were significantly (P < 0.001) reduced in the group treated with MB + PEG combined with laser.

CONCLUSION

MB-PEG based hydrogel improves and accelerates wound closure in the context of laser compared to either single treatment.

Sex differences in adverse events in Medicare individuals ≥ 66 years of age post glioblastoma treatment

PURPOSE

Glioblastoma (GB) is the most common primary malignant brain tumor with the highest incidence occurring in older adults with a median age at diagnosis of 64 years old. While treatment often improves survival it brings toxicities and adverse events (AE). Here we identify sex differences in treatment patterns and AE in individuals ≥ 66 years at diagnosis with GB.

METHODS

Using the SEER-Medicare dataset sex differences in adverse events were assessed using multivariable logistic regression performed to calculate the male/female odds ratio (M/F OR) and 95% confidence intervals [95% CI] of experiencing an AE adjusted for demographic variables and Elixhauser comorbidity score.

RESULTS

Males with GB were more likely to receive standard of care (SOC; Surgery with concurrent radio-chemotherapy) [20%] compared to females [17%], whereas females were more likely to receive no treatment [26%] compared to males [21%]. Females with GB receiving SOC were more likely to develop gastrointestinal disorders (M/F OR = 0.76; 95% CI,0.64-0.91, p = 0.002) or blood and lymphatic system disorders (M/F OR = 0.79; 95% CI,0.66-0.95, p = 0.012). Males with GB receiving SOC were more likely to develop cardiac disorders (M/F OR = 1.21; 95% CI,1.02-1.44, p = 0.029) and renal disorders (M/F OR = 1.65; 95% CI,1.37-2.01, p < 0.001).

CONCLUSIONS

Sex differences for individuals, 66 years and older, diagnosed with GB exist in treatment received and adverse events developed across different treatment modalities.

Health Care Cost Reductions with Machine Learning-Directed Evaluations during Radiation Therapy - An Economic Analysis of a Randomized Controlled Study

BACKGROUND

Machine learning (ML) may cost-effectively direct health care by identifying patients most likely to benefit from preventative interventions to avoid negative and expensive outcomes. System for High-Intensity Evaluation During Radiation Therapy (SHIELD-RT; NCT04277650) was a single-institution, randomized controlled study in which electronic health record-based ML accurately identified patients at high risk for acute care (emergency visit or hospitalization) during radiotherapy (RT) and targeted them for supplemental clinical evaluations. This ML-directed intervention resulted in decreased acute care utilization. Given the limited prospective data showing the ability of ML to direct interventions cost-efficiently, an economic analysis was performed.

METHODS

A post hoc economic analysis was conducted of SHIELD-RT that included RT courses from January 7, 2019, to June 30, 2019. ML-identified high-risk courses (≥10% risk of acute care during RT) were randomized to receive standard of care weekly clinical evaluations with ad hoc supplemental evaluations per clinician discretion versus mandatory twice-weekly evaluations. The primary outcome was difference in mean total medical costs during and 15 days after RT. Acute care costs were obtained via institutional cost accounting. Physician and intervention costs were estimated via Medicare and Medicaid data. Negative binomial regression was used to estimate cost outcomes after adjustment for patient and disease factors.

RESULTS

A total of 311 high-risk RT courses among 305 patients were randomized to the standard (n=157) or the intervention (n=154) group. Unadjusted mean intervention group supplemental visit costs were $155 per course (95% confidence interval, $142 to $168). The intervention group had fewer acute care visits per course (standard, 0.47; intervention, 0.31; P=0.04). Total mean adjusted costs were $3110 per course for the standard group and $1494 for the intervention group (difference in means, $1616 [95% confidence interval, $1450 to $1783]; P=0.03).

CONCLUSIONS

In this economic analysis of a randomized controlled, health care ML study, mandatory supplemental evaluations for ML-identified high-risk patients were associated with both reduced total medical costs and improved clinical outcomes. Further study is needed to determine whether economic results are generalizable. (Funded in part by The Duke Endowment, The Conquer Cancer Foundation, the Duke Department of Radiation Oncology, and the National Cancer Institute of the National Institutes of Health [R01CA277782]; ClinicalTrials.gov number, NCT04277650.).

Effects on Quality of Life of a Telemonitoring Platform amongst Patients with Cancer (EQUALITE): A Randomized Trial Protocol

Cancer, a pervasive global health challenge, necessitates chemotherapy or radiotherapy treatments for many prevalent forms. However, traditional follow-up approaches encounter limitations, exacerbated by the recent COVID-19 pandemic. Consequently, telemonitoring has emerged as a promising solution, although its clinical implementation lacks comprehensive evidence. This report depicts the methodology of a randomized trial which aims to investigate whether leveraging a smartphone app called Contigo for disease monitoring enhances self-reported quality of life among patients with various solid cancers compared to standard care. Secondary objectives encompass evaluating the app's impact on depressive symptoms and assessing adherence to in-person appointments. Randomization will be performed independently using an allocation sequence that will be kept concealed from clinical investigators. Contigo offers two primary functions: monitoring cancer patients' progress and providing educational content to assist patients in managing common clinical situations related to their disease. The study will assess outcomes such as quality of life changes and depressive symptom development using validated scales, and adherence to in-person appointments. Specific scales include the EuroQol Group's EQ-5D questionnaire and the Patient Health Questionnaire (PHQ-9). We hypothesize that the use of Contigo will assist and empower patients receiving cancer treatment, which will translate to better quality of life scores and a reduced incidence of depressive symptoms. All analyses will be undertaken with the intention-to-treat principle by a statistician unaware of treatment allocation. This trial is registered in ClinicalTrials under the registration number NCT06086990.

Effects of Patient-Reported Outcome Tracking and Health Information Provision via Remote Patient Monitoring Software on Patient Outcomes in Oncology Care: A Systematic Review and Meta-Analysis

OBJECTIVES

The authors sought to 1) review the literature on the remote care model that uses remote patient monitoring software (RPMS) as key mechanisms in oncology care for symptom tracking and health information provision and (2) compare the remote care model to standard care in terms of health-related quality of life, symptom burden, health management self-efficacy, anxiety, and depression.

DATA SOURCES

The search was conducted on March 23, 2022, in the Cochrane Library, MEDLINE/PubMed, PsycINFO, and CINAHL databases.

RESULTS

The primary strategies for applying digital technology in remote care models are patient-reported outcomes (PRO) tracking and health information delivery. Common PRO measurements applied in the RPMS include quality of life, symptom burden, self-efficacy, anxiety, and depression. Nine randomized controlled trials testing seven RPMS interventions were examined. Compared to standard care, remote patient monitoring via RPMS was related to greater quality of life and lower physical symptom burden during cancer therapy. The RPMS incorporated into routine clinical care with nurses providing remote monitoring performed better on PRO than that not integrated.

CONCLUSION

The RPMS-based remote care model improves patient outcomes during cancer treatment, and it is not inferior to standard care until the RPMS function is more integrated with existing clinical care.

IMPLICATIONS FOR NURSING PRACTICE

Nurses are well-positioned to engage patients in self-care skills via RPMS and can play a vital role in integrating such a model of remote patient care into routine care practices.

Sepsis and acute respiratory failure in patients with cancer: how can we improve care and outcomes even further?

PURPOSE OF REVIEW

Care and outcomes of critically ill patients with cancer have improved over the past decade. This selective review will discuss recent updates in sepsis and acute respiratory failure among patients with cancer, with particular focus on important opportunities to improve outcomes further through attention to phenotyping, predictive analytics, and improved outcome measures.

RECENT FINDINGS

The prevalence of cancer diagnoses in intensive care units (ICUs) is nontrivial and increasing. Sepsis and acute respiratory failure remain the most common critical illness syndromes affecting these patients, although other complications are also frequent. Recent research in oncologic sepsis has described outcome variation - including ICU, hospital, and 28-day mortality - across different types of cancer (e.g., solid vs. hematologic malignancies) and different sepsis definitions (e.g., Sepsis-3 vs. prior definitions). Research in acute respiratory failure in oncology patients has highlighted continued uncertainty in the value of diagnostic bronchoscopy for some patients and in the optimal respiratory support strategy. For both of these syndromes, specific challenges include multifactorial heterogeneity (e.g. in etiology and/or underlying cancer), delayed recognition of clinical deterioration, and complex outcomes measurement.

SUMMARY

Improving outcomes in oncologic critical care requires attention to the heterogeneity of cancer diagnoses, timely recognition and management of critical illness, and defining appropriate ICU outcomes.

Readmission rates and outcomes in adults with and without COVID-19 following inpatient chemotherapy admission: A nationwide analysis

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has received considerable attention in the scientific community due to its impact on healthcare systems and various diseases. However, little focus has been given to its effect on cancer treatment.

AIM

To determine the effect of COVID-19 pandemic on cancer patients' care.

METHODS

A retrospective review of a Nationwide Readmission Database (NRD) was conducted to analyze hospitalization patterns of patients receiving inpatient chemotherapy (IPCT) during the COVID-19 pandemic in 2020. Two cohorts were defined based on readmission within 30 d and 90 d. Demographic information, readmission rates, hospital-specific variables, length of hospital stay (LOS), and treatment costs were analyzed. Comorbidities were assessed using the Elixhauser comorbidity index. Multivariate Cox regression analysis was performed to identify independent predictors of readmission. Statistical analysis was conducted using Stata® Version 16 software. As the NRD data is anonymous and cannot be used to identify patients, institutional review board approval was not required for this study.

RESULTS

A total of 87755 hospitalizations for IPCT were identified during the pandemic. Among the 30-day index admission cohort, 55005 patients were included, with 32903 readmissions observed, resulting in a readmission rate of 59.8%. For the 90-day index admission cohort, 33142 patients were included, with 24503 readmissions observed, leading to a readmission rate of 73.93%. The most common causes of readmission included encounters with chemotherapy (66.7%), neutropenia (4.36%), and sepsis (3.3%). Comorbidities were significantly higher among readmitted hospitalizations compared to index hospitalizations in both readmission cohorts. The total cost of readmission for both cohorts amounted to 1193000000.00 dollars. Major predictors of 30-day readmission included peripheral vascular disorders [Hazard ratio (HR) = 1.09, P < 0.05], paralysis (HR = 1.26, P < 0.001), and human immunodeficiency virus/acquired immuno-deficiency syndrome (HR = 1.14, P = 0.03). Predictors of 90-day readmission included lymphoma (HR = 1.14, P < 0.01), paralysis (HR = 1.21, P = 0.02), and peripheral vascular disorders (HR = 1.15, P < 0.01).

CONCLUSION

The COVID-19 pandemic has significantly impacted the management of patients undergoing IPCT. These findings highlight the urgent need for a more strategic approach to the care of patients receiving IPCT during pandemics.

Integrated transcriptomic and metabolomic profiles reveal the protective mechanism of modified Danggui Buxue decoction on radiation-induced leukopenia in mice

Leukopenia caused by radiation hinders the continuous treatment of cancers. Danggui Buxue Decoction (DBD) has been widely used in clinical owing to low toxicity and definite therapeutic effects to increase leukocytes. Meanwhile, icaritin (ICT) has also been proved to have the effect of boosting peripheral blood cells proliferation. However, there is no study to prove the efficacy of MDBD (Modified Danggui Buxue Decoction), a derivative herbal formula composed of DBD and ICT, in the treatment of radiation-induced leukopenia. In this study, we performed a model of 3.5 Gy whole-body radiation to induce leukopenia in mice. The results of pharmacodynamic studies demonstrated that MDBD could significantly increase the white blood cells in peripheral blood by improving the activity of bone marrow nuclear cells, reducing bone marrow damage, modulating spleen index, and regulating hematopoietic factors to alleviate leukopenia. We also analyzed the integrated results of metabolomics and transcriptomics and found that MDBD could relieve leukopenia and alleviate bone marrow damage by targeting steroid biosynthesis and IL-17 signaling pathway, in which the key genes are Jun, Cxcl2 and Egr1. Therefore, our study provides a basis for the effectiveness and compatibility in the combination of traditional Chinese medicine formula and small molecule drugs.

Survivin Expression in Luminal Breast Cancer and Adjacent Normal Tissue for Immuno-Oncology Applications

Survivin (BIRC5) is a tumor-associated antigen (TAA) overexpressed in various tumors but present at low to undetectable levels in normal tissue. Survivin is known to have a high expression in breast cancer (e.g., Ductal Carcinoma in situ (DCIS) and triple negative breast cancer). Previous studies have not compared survivin expression levels in DCIS tumor samples to levels in adjacent, normal breast tissue from the same patient. To ensure the effective use of survivin as a target for T cell immunotherapy of breast cancer, it is essential to ascertain the varying levels of survivin expression between DCIS tumor tissue samples and the adjacent normal breast tissue taken from the same patient simultaneously. Next-generation sequencing of RNA (RNA-seq) in normal breast tissue and tumor breast tissue from five women presenting with DCIS for lumpectomy was used to identify sequence variation and expression levels of survivin. The identity of both tumor and adjacent normal tissue samples were corroborated by histopathology. Survivin was overexpressed in human breast tissue tumor samples relative to the corresponding adjacent human normal breast tissue. Wild-type survivin transcripts were the predominant species identified in all tumor tissue sequenced. This study demonstrates upregulated expression of wild type survivin in DCIS tumor tissue versus normal breast tissue taken from the same patient at the same time, and provides evidence that developing selective cytotoxic T lymphocyte (CTL) immunotherapy for DCIS targeting survivin warrants further study.

A Web-Based Cancer Self-Management Program (I-Can Manage) Targeting Treatment Toxicities and Health Behaviors: Human-Centered Co-design Approach and Cognitive Think-Aloud Usability Testing

BACKGROUND

Patients with cancer require adequate preparation in self-management of treatment toxicities to reduce morbidity that can be achieved through well-designed digital technologies that are developed in co-design with patients and end users.

OBJECTIVE

We undertook a user-centered co-design process in partnership with patients and other knowledge end users to develop and iteratively test an evidence-based and theoretically informed web-based cancer self-management program (I-Can Manage). The specific study aims addressed in 2 phases were to (1) identify from the perspective of patients with cancer and clinicians the desired content, features, and functionalities for an online self-management education and support (SMES) program to enable patient self-management of treatment toxicities (phase 1); (2) develop the SMES prototype based on human-centered, health literate design principles and co-design processes; and (3) evaluate usability of the I-Can Manage prototype through user-centered testing (phase 2).

METHODS

We developed the I-Can Manage program using multiperspective data sources and based on humanistic and co-design principles with end users engaged through 5 phases of development. We recruited adult patients with lung, colorectal, and lymphoma cancer receiving systemic treatments from ambulatory clinics in 2 regional cancer programs for the qualitative inquiry phase. The design of the program was informed by data from qualitative interviews and focus groups, persona and journey mapping, theoretical underpinnings of social cognitive learning theory, and formalized usability testing using a cognitive think-aloud process and user satisfaction survey. A co-design team comprising key stakeholders (human design experts, patients/caregiver, clinicians, knowledge end users, and e-learning and digital design experts) was involved in the developmental process. We used a cognitive think-aloud process to test usability and participants completed the Post-Study System Usability Questionnaire (PSSUQ).

RESULTS

In the initial qualitative inquiry phase, 16 patients participated in interviews and 19 clinicians participated in interviews or focus groups and 12 key stakeholders participated in a persona journey mapping workshop to inform development of the program prototype. The I-Can Manage program integrates evidence-based information and strategies for the self-management of treatment toxicities and health-promoting behaviors in 6 e-learning modules (lay termed "chapters"), starting with an orientation to self-management. Behavioral exercises, patient written and video stories, downloadable learning resources, and online completion of goals and action plans were integrated across chapters. Patient participants (n=5) with different cancers, gender, and age worked through the program in the human factors laboratory using a cognitive think-aloud process and all key stakeholders reviewed each chapter of the program and approved revisions. Results of the PSSUQ (mean total score: 3.75) completed following the cognitive think-aloud process (n=5) suggest patient satisfaction with the usability of I-Can Manage.

CONCLUSIONS

The I-Can Manage program has the potential for activating patients in self-management of cancer and treatment toxicities but requires testing in a larger randomized controlled trial.

Wearable based monitoring and self-supervised contrastive learning detect clinical complications during treatment of Hematologic malignancies

Serious clinical complications (SCC; CTCAE grade ≥ 3) occur frequently in patients treated for hematological malignancies. Early diagnosis and treatment of SCC are essential to improve outcomes. Here we report a deep learning model-derived SCC-Score to detect and predict SCC from time-series data recorded continuously by a medical wearable. In this single-arm, single-center, observational cohort study, vital signs and physical activity were recorded with a wearable for 31,234 h in 79 patients (54 Inpatient Cohort (IC)/25 Outpatient Cohort (OC)). Hours with normal physical functioning without evidence of SCC (regular hours) were presented to a deep neural network that was trained by a self-supervised contrastive learning objective to extract features from the time series that are typical in regular periods. The model was used to calculate a SCC-Score that measures the dissimilarity to regular features. Detection and prediction performance of the SCC-Score was compared to clinical documentation of SCC (AUROC ± SD). In total 124 clinically documented SCC occurred in the IC, 16 in the OC. Detection of SCC was achieved in the IC with a sensitivity of 79.7% and specificity of 87.9%, with AUROC of 0.91 ± 0.01 (OC sensitivity 77.4%, specificity 81.8%, AUROC 0.87 ± 0.02). Prediction of infectious SCC was possible up to 2 days before clinical diagnosis (AUROC 0.90 at -24 h and 0.88 at -48 h). We provide proof of principle for the detection and prediction of SCC in patients treated for hematological malignancies using wearable data and a deep learning model. As a consequence, remote patient monitoring may enable pre-emptive complication management.

An artificial neural network-based radiomics model for predicting the radiotherapy response of advanced esophageal squamous cell carcinoma patients: a multicenter study

Radiotherapy benefits patients with advanced esophageal squamous cell carcinoma (ESCC) in terms of symptom relief and long-term survival. In contrast, a substantial proportion of ESCC patients have not benefited from radiotherapy. This study aimed to establish and validate an artificial neural network-based radiomics model for the pretreatment prediction of the radiotherapy response of advanced ESCC by using integrated data combined with feasible baseline characteristics of computed tomography. A total of 248 patients with advanced ESCC who underwent baseline CT and received radiotherapy were enrolled in this study and were analyzed by two types of radiomics models, machine learning and deep learning. As a result, the Att. Resnet50 pretrained network model indicated superior performance, with AUCs of 0.876, 0.802 and 0.732 in the training, internal validation, and external validation cohorts, respectively. Similarly, our Att. Resnet50 pretrained network model showed excellent calibration and significant clinical benefit according to the C index and decision curve analysis. Herein, a novel pretreatment radiomics model was established based on deep learning methods and could be used for radiotherapy response prediction in advanced ESCC patients, thus providing reliable evidence for therapeutic decision-making.

New Methacrylated Biopolymer-Based Hydrogels as Localized Drug Delivery Systems in Skin Cancer Therapy

The aim of the present work was to obtain drug-loaded hydrogels based on combinations of dextran, chitosan/gelatin/xanthan, and poly (acrylamide) as a sustained and controlled release vehicle of Doxorubicin, a drug used in skin cancer therapy that is associated with severe side effects. Hydrogels for use as 3D hydrophilic networks with good manipulation characteristics were produced using methacrylated biopolymer derivatives and the methacrylate group's polymerization with synthetic monomers in the presence of a photo-initiator, under UV light stimulation (365 nm). Transformed infrared spectroscopy analysis (FT-IR) confirmed the hydrogels' network structure (natural-synthetic composition and photocrosslinking), while scanning electron microscopy (SEM) analysis confirmed the microporous morphology. The hydrogels are swellable in simulated biological fluids and the material's morphology regulates the swelling properties: the maximum swelling degree was obtained for dextran-chitosan-based hydrogels because of their higher porosity and pore distribution. The hydrogels are bioadhesive on a biological simulating membrane, and values for the force of detachment and work of adhesion are recommended for applications on skin tissue. The Doxorubicin was loaded into the hydrogels and the drug was released by diffusion for all the resulting hydrogels, with small contributions from the hydrogel networks' relaxation. Doxorubicin-loaded hydrogels are efficient on keratinocytes tumor cells, the sustained released drug interrupting the cells' division and inducing cell apoptosis; we recommend the obtained materials for the topical treatment of cutaneous squamous cell carcinoma.

SQ3370, the first clinical click chemistry-activated cancer therapeutic, shows safety in humans and translatability across species

BACKGROUND

SQ3370 is the first demonstration of the Click Activated Protodrugs Against Cancer (CAPAC™) platform that uses click chemistry to activate drugs directly at tumor sites, maximizing therapeutic exposure. SQ3370 consists of a tumor-localizing biopolymer (SQL70) and a chemically-attenuated doxorubicin (Dox) protodrug SQP33; the protodrug is activated upon clicking with the biopolymer at tumor sites. Here, we present data from preclinical studies and a Phase 1 dose-escalation clinical trial in adult patients with advanced solid tumors ( NCT04106492 ) demonstrating SQ3370's activation at tumor sites, safety, systemic pharmacokinetics (PK), and immunological activity.

METHODS

Treatment cycles consisting of an intratumoral or subcutaneous injection of SQL70 biopolymer followed by 5 daily intravenous doses of SQP33 protodrug were evaluated in tumor-bearing mice, healthy dogs, and adult patients with solid tumors.

RESULTS

SQL70 effectively activated SQP33 at tumor sites, resulting in high Dox concentrations that were well tolerated and unachievable by conventional treatment. SQ3370 was safely administered at 8.9x the veterinary Dox dose in dogs and 12x the conventional Dox dose in patients, with no dose-limiting toxicity reported to date. SQ3370's safety, toxicology, and PK profiles were highly translatable across species. SQ3370 increased cytotoxic CD3 ⁺ and CD8 ⁺ T-cells in patient tumors indicating T-cell-dependent immune activation in the tumor microenvironment.

CONCLUSIONS

SQ3370, the initial demonstration of click chemistry in humans, enhances the safety of Dox at unprecedented doses and has the potential to increase therapeutic index. Consistent safety, toxicology, PK, and immune activation results observed with SQ3370 across species highlight the translatability of the click chemistry approach in drug development.

TRIAL REGISTRATION

NCT04106492; 7 September 2019.

Lung cancer in the emergency department

Background

Though decreasing in incidence and mortality in the USA, lung cancer remains the deadliest of all cancers. For a significant number of patients, the emergency department (ED) provides the first pivotal step in lung cancer prevention, diagnosis, and management. As screening recommendations and treatments advance, ED providers must stay up-to-date with the latest lung cancer recommendations. The purpose of this review is to identify the many ways that emergency providers may intersect with the disease spectrum of lung cancer and provide an updated array of knowledge regarding detection, management, complications, and interdisciplinary care.

Findings

Lung cancer, encompassing 10-12% of cancer-related emergency department visits and a 66% admission rate, is the most fatal malignancy in both men and women. Most patients presenting to the ED have not seen a primary care provider or undergone screening. Ultimately, half of those with a new lung cancer diagnosis in the ED die within 1 year. Incidental findings on computed tomography are mostly benign, but emergency staff must be aware of the factors that make them high risk. Radiologic presentations range from asymptomatic nodules to diffuse metastatic lesions with predominately pulmonary symptoms, and some may present with extra-thoracic manifestations including neurologic. The short-term prognosis for ED lung cancer patients is worse than that of other malignancies. Screening offers new hope through earlier diagnosis but is underutilized which may be due to racial and socioeconomic disparities. New treatments provide optimism but lead to new complications, some long-term. Multidisciplinary care is essential, and emergency medicine is responsible for the disposition of patients to the appropriate specialists at inpatient and outpatient centers.

Conclusion

ED providers are intimately involved in all aspects of lung cancer care. Risk factor modification and referral for lung cancer screening are opportunities to further enhance patient care. In addition, with the advent of newer cancer therapies, ED providers must stay vigilant and up-to-date with all aspects of lung cancer including disparities, staging, symptoms of disease, prognosis, treatment, and therapy-related complications.

Application of big data analyses to compare the impact of oral and gastrointestinal mucositis on risks and outcomes of febrile neutropenia and septicemia among patients hospitalized for the treatment of leukemia or multiple myeloma

PURPOSE

Oral ulcerative mucositis (UM) and gastrointestinal mucositis (GIM) have been associated with increased likelihood of systemic infection (bacteremia and sepsis) in patients being treated for hematological malignancies. To better define and contrast differences between UM and GIM, we utilized the United States 2017 National Inpatient Sample and analyzed patients hospitalized for the treatment of multiple myeloma (MM) or leukemia.

METHODS

We utilized generalized linear models to assess the association between adverse events-UM and GIM-among hospitalized MM or leukemia patients and the outcome of febrile neutropenia (FN), septicemia, burden of illness, and mortality.

RESULTS

Of 71,780 hospitalized leukemia patients, 1255 had UM and 100 GIM. Of 113,915 MM patients, 1065 manifested UM and 230 had GIM. In an adjusted analysis, UM was significantly associated with increased risk of FN in both the leukemia (aOR = 2.87, 95% CI = 2.09-3.92) and MM cohorts (aOR = 4.96, 95% CI = 3.22-7.66). Contrastingly, UM had no effect on the risk of septicemia in either group. Likewise, GIM significantly increased the odds of FN in both leukemia (aOR = 2.81, 95% CI = 1.35-5.88) and MM (aOR = 3.75, 95% CI = 1.51-9.31) patients. Similar findings were noted when we restricted our analysis to recipients of high-dose condition regimens in preparation for hematopoietic stem-cell transplant. UM and GIM were consistently associated with higher burden of illness in all the cohorts.

CONCLUSION

This first use of big data provided an effective platform to assess the risks, outcomes, and cost of care of cancer treatment-related toxicities in patients hospitalized for the management of hematologic malignancies.

Comparison of Oncologist and Model Estimates of Risk for Hospitalization During Systemic Therapy for Advanced Cancer

PURPOSE

A validated risk model with inputs of pretreatment sodium and albumin can identify patients at risk for hospitalization during cancer treatment. We evaluated how the model compares with risk estimates from treating oncologists.

METHODS

We evaluated the 30-day risk of hospitalization or death in patients starting palliative-intent systemic therapy for solid tumor malignancy. For each patient, we prospectively recorded categorical estimates of 30-day hospitalization risk (bottom third, middle third, top third) generated by a treating oncologist and by the two-variable model; a third hybrid risk estimate represented a composite of the oncologist and model risk assessments. We analyzed the agreement of oncologist and model-based risk estimates and compared discrimination, sensitivity, and specificity of each risk assessment method.

RESULTS

We collected oncologist, model, and hybrid estimates of hospitalization risk for 120 patients. The 30-day rate of hospitalization or death was 20%. There was minimal agreement between oncologist and model risk estimates (weighted kappa = 0.27). The c-statistic (a measure of discrimination) was 0.69 (95% CI, 0.57 to 0.81) for the clinician assessment, 0.77 for the model assessment (CI, 0.67 to 0.86; P = .24 compared with the oncologist assessment), and 0.79 for the hybrid assessment (CI, 0.69 to 0.90; P = .007 compared with the oncologist assessment). Sensitivity and specificity of the high-risk categorization did not differ significantly between the oncologist and model assessments; the hybrid assessment was significantly more sensitive (P = .02) and less specific (P = .03) than the oncologist assessment.

CONCLUSION

A model with inputs of pretreatment sodium and albumin improves oncologists' predictions of hospitalization risk during cancer treatment.

Imaging Recommendations for Diagnosis, Staging and Management of Treatment-Related Complications in Cancer

Precision medicine is becoming increasingly common in oncology, with treatments tailored to individual patients and cancer. By integrating these underlying concepts of health care, chemotherapy and radiotherapy can be tailored to improve safety and efficacy. On the other hand, oncology treatment regimens may result in local and systemic changes and complications depending on the type of treatment. For the proper and prompt management of cancer patients, it is essential to interpret this posttreatment imaging correctly. This article aims at guiding treating physicians to be able to distinguish complications from expected posttreatment changes.

Healthcare provider evaluation of machine learning-directed care: reactions to deployment on a randomised controlled study

OBJECTIVES

Clinical artificial intelligence and machine learning (ML) face barriers related to implementation and trust. There have been few prospective opportunities to evaluate these concerns. System for High Intensity EvaLuation During Radiotherapy (NCT03775265) was a randomised controlled study demonstrating that ML accurately directed clinical evaluations to reduce acute care during cancer radiotherapy. We characterised subsequent perceptions and barriers to implementation.

METHODS

An anonymous 7-question Likert-type scale survey with optional free text was administered to multidisciplinary staff focused on workflow, agreement with ML and patient experience.

RESULTS

59/71 (83%) responded. 81% disagreed/strongly disagreed their workflow was disrupted. 67% agreed/strongly agreed patients undergoing intervention were high risk. 75% agreed/strongly agreed they would implement the ML approach routinely if the study was positive. Free-text feedback focused on patient education and ML predictions.

CONCLUSIONS

Randomised data and firsthand experience support positive reception of clinical ML. Providers highlighted future priorities, including patient counselling and workflow optimisation.

Inoperable Bowel Obstruction in Ovarian Cancer: Prevalence, Impact and Management Challenges

Malignant bowel obstruction (MBO) is one of the most severe complications in patients with advanced ovarian cancer, with an estimated incidence up to 50%. Its presence is related to poor prognosis and a life expectancy measured in weeks for inoperable cases. Symptoms are usually difficult to manage and often require hospitalization, which carries a high burden on patients, caregivers and the healthcare system. Management is complex and requires a multidisciplinary approach to improve clinical outcomes. Patients with inoperable MBO are treated medically with analgesics, antiemetics, steroids and antisecretory agents. Parenteral nutrition and gut decompression with nasogastric tube, venting gastrostomy or stenting may be used as supportive therapy. Treatment decision-making is challenging and often based on clinical expertise and local policies, with lack of high-quality evidence to optimally standardize management. The present review summarizes current literature on inoperable bowel obstruction in ovarian cancer, focusing on epidemiology, prognostic factors, clinical outcomes, medical management, multidisciplinary interventions and quality of life.

What Causes Death in Esophageal Cancer Patients Other Than the Cancer Itself: A Large Population-Based Analysis

Background: Researches on noncancer causes of death in patients with esophageal cancer (EC) are not in-depth. The objective of this paper is to broadly and deeply explore the causes of death in patients with EC, especially noncancer causes.

Methods: Information about the demographics, tumor-related characteristics, and causes of death of patients with EC who met the inclusion criteria were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Calculated standardized mortality ratio (SMR) for all causes of death at different follow-up times and performed subgroup analyses.

Results: In total, 63,560 patients with EC were retrieved from the public database. And 52,503 died during the follow-up period. Most deaths were due to EC itself within 5 years after diagnosis, but over 10 years, 59% EC patients died from noncancer causes. Cardiovascular disease was the major noncancer cause of death in patients with EC, accounting for 43%. Suicide and self-injury (2%) of EC patients should not be ignored. During the 1-year follow-up period, patients with EC had statistically highest risk of death from septicemia (SMR: 7.61; 95% CI: 6.38-9.00). Within more than 10 years after EC diagnosis, more and more patients died from chronic obstructive pulmonary disease (SMR: 2.38; 95% CI: 1.79-3.10).

Conclusions: Although most patients with EC still died from the cancer itself, the role of noncancer causes of death should not be underestimated. These prompt clinicians to pay more attention to the risk of death caused by these noncancer causes, which can provide relevant measures in advance to intervene.

Implementation of machine learning in the clinic: challenges and lessons in prospective deployment from the System for High Intensity EvaLuation During Radiation Therapy (SHIELD-RT) randomized controlled study

Background

Artificial intelligence (AI) and machine learning (ML) have resulted in significant enthusiasm for their promise in healthcare. Despite this, prospective randomized controlled trials and successful clinical implementation remain limited. One clinical application of ML is mitigation of the increased risk for acute care during outpatient cancer therapy. We previously reported the results of the System for High Intensity EvaLuation During Radiation Therapy (SHIELD-RT) study (NCT04277650), which was a prospective, randomized quality improvement study demonstrating that ML based on electronic health record (EHR) data can direct supplemental clinical evaluations and reduce the rate of acute care during cancer radiotherapy with and without chemotherapy. The objective of this study is to report the workflow and operational challenges encountered during ML implementation on the SHIELD-RT study.

Results

Data extraction and manual review steps in the workflow represented significant time commitments for implementation of clinical ML on a prospective, randomized study. Barriers include limited data availability through the standard clinical workflow and commercial products, the need to aggregate data from multiple sources, and logistical challenges from altering the standard clinical workflow to deliver adaptive care.

Conclusions

The SHIELD-RT study was an early randomized controlled study which enabled assessment of barriers to clinical ML implementation, specifically those which leverage the EHR. These challenges build on a growing body of literature and may provide lessons for future healthcare ML adoption.

Trial registration: NCT04277650. Registered 20 February 2020. Retrospectively registered quality improvement study.

Sexual dimorphism in gut microbiota dictates therapeutic efficacy of intravenous immunoglobulin on radiotherapy complications

INTRODUCTION

With the mounting number of cancer survivors, the complications following cancer treatment become novel conundrums and starve for countermeasures. Intravenous immunoglobulin (IVIg) is a purified preparation for immune-deficient and autoimmune conditions.

OBJECTIVES

Here, we investigated whether IVIg could be employed to fight against radiation injuries and explored the underlying mechanism.

METHODS

Hematopoietic or gastrointestinal (GI) tract toxicity was induced by total body or abdominal local irradiation. High-throughput sequencing was performed to analyze the gut microbiota configurations and gene expression profile of small intestine. The untargeted metabolomics of gut microbiome was assessed by liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS) analyses. Hydrodynamic-based gene delivery was used to knockdown the target genes in vivo.

RESULTS

Intravenous injection of IVIg protected against radiation-induced hematopoietic and GI tract toxicity in female mice but not in males. IVIg structured sex-characteristic gut microbiota configurations in abdominal irradiated mice. The irradiation enriched gut Lachnospiraceae in female mice but reduced those in males. IVIg injection combined with oral gavage of Lachnospiraceae or its metabolite hypoxanthine, alleviated radiation toxicity in male mice however, Lachnospiraceae or hypoxanthine alone failed to ameliorate the injuries. Abdominal local irradiation drove sex-distinct gene expression signatures in small intestine. Mechanistic investigation showed that replenishment of Lachnospiraceae or hypoxanthine offset abdominal radiation-reduced PLD1 expression in male mice. In females, irradiation elevated PLD1 expression. Deletion of PLD1 in GI tract of female mice erased the radioprotective effects of IVIg.

CONCLUSION

IVIg battles against radiation injuries in a sex-specific, gut microbiome-dependent way through Lachnospiraceae/hypoxanthine/PLD1 axis. Our findings provide a sex-precise therapeutic avenue to improve the prognosis of cancer patients with radiotherapy in pre-clinical settings.

MASCC multidisciplinary evidence-based recommendations for the management of malignant bowel obstruction in advanced cancer

PURPOSE

To provide evidence-based recommendations on the management of malignant bowel obstruction (MBO) for patients with advanced cancer.

METHODS

The Multinational Association for Supportive Care in Cancer (MASCC) MBO study group conducted a systematic review of databases (inception to March 2021) to identify studies about patients with advanced cancer and MBO that reported on the following outcomes: symptom management, bowel obstruction resolution, prognosis, overall survival, and quality of life. The review was restricted to studies published in English, but no restrictions were placed on publication year, country, and study type. As per the MASCC Guidelines Policy, the findings were synthesized to determine the levels of evidence to support each MBO intervention and, ultimately, the graded recommendations and suggestions.

RESULTS

The systematic review identified 17,656 published studies and 397 selected for the guidelines. The MASCC study group developed a total of 25 evidence-based suggestions and recommendations about the management of MBO-related nausea and vomiting, bowel movements, pain, inflammation, bowel decompression, and nutrition. Expert consensus-based guidance about advanced care planning and psychosocial support is also provided.

CONCLUSION

This MASCC Guideline provides comprehensive, evidence-based recommendations about MBO management for patients with advanced cancer.

Relative Incidence of Emergency Department Visits After Treatment for Prostate Cancer with Radiation Therapy or Radical Prostatectomy

PURPOSE

Side effect profiles play an important role in treatment decisions for localized prostate cancer. Emergency department (ED) visits, which may be due to side effects from treatment, can be measured in real-world, structured, electronic health record (EHR) data. The goal of this study was to determine whether treatments for localized prostate cancer are associated with ED visits, as a measure of side effects, using EHR data.

METHODS AND MATERIALS

We used a self-controlled case series study (SCCS) design, including patients treated at an urban academic medical center with radiation therapy (RT) or radical prostatectomy (RP) for prostate cancer between 2011 and 2020 who had visits documented for ≥ 6 months before and after treatment and ≥1 ED visit. We estimated relative incidences (RI) of ED visits, comparing incidence in the exposed and unexposed periods, with the exposed period being between start of treatment and 1 month after completion, and the unexposed period consisting of all other documented time.

RESULTS

Among men who had at least one ED visit and after adjusting for age, there were higher rates of ED visits after RP (RI 20.4, 95% confidence interval [CI] 15.4-27.0, p<0.001), RT overall (RI 2.4, CI 1.7-3.4, p<0.001), intensity modulated radiation therapy with high dose-rate brachytherapy (HDR) (RI 3.4, CI 1.7-6.8, p<0.001) or stereotactic body radiation therapy boost (RI 7.1, CI 3.4-14.8, p < 0.001), and HDR alone (RI 16.3, CI 7.2-36.9, p<0.001), compared to unexposed time. The number needed to harm to result in an ED visit was less for RP (17, CI 13-23) than RT overall (43, CI 25-126), but varied by RT modality.

CONCLUSIONS

In summary, relative rates of ED visits vary by treatment type, suggesting differing severities of side effects. These data may aid in selecting treatments and demonstrate the feasibility of using the SCCS study design on ED visits in real-world, structured EHR data to better understand side effects of treatment.

Disadvantaged Subgroups Within the Global Head and Neck Cancer Population: How Can We Optimize Care?

Within the global head and neck cancer population, there are subgroups of patients with poorer cancer outcomes independent from tumor characteristics. In this article, we review three such groups. The first group comprises patients with nasopharyngeal cancer in low- and middle-income countries where access to high-volume, well-resourced radiotherapy centers is limited. We discuss a recent study that is aiming to improve outcomes through the instigation of a comprehensive radiotherapy quality assurance program. The second group comprises patients with low socioeconomic status in a high-income country who experience substantial financial toxicity, defined as financial hardship for patients due to health care costs. We review causes and consequences of financial toxicity and discuss how it can be mitigated. The third group comprises older patients who may poorly tolerate and not benefit from intensive standard-of-care treatment. We discuss the role of geriatric assessment, particularly in relation to the use of chemotherapy. Through better recognition and understanding of disadvantaged groups within the global head and neck cancer population, we will be better placed to instigate the necessary changes to improve outcomes and quality of life for patients with head and neck cancer.

Opportunities to use electronic health record audit logs to improve cancer care

The rapid adoption of electronic health records (EHRs) has created extensive repositories of digitized data that can be used to inform improvements in care delivery, processes, and patient outcomes. While the clinical data captured in EHRs are widely used for such efforts, EHRs also capture audit log data that reflect how users interact with the EHR to deliver care. Automatically collected audit log data provide a unique opportunity for new insights into EHR user behavior and decision‐making processes. Here, we provide an overview of audit log data and examples that could be used to improve oncology care and outcomes in four domains: diagnostic reasoning and consumption, care team collaboration and communication, patient outcomes and experience, and provider burnout/fatigue. This data source could identify gaps in performance and care, physician uptake of EHR features that enhance decision‐making, and integration of data trends for oncology. Ensuring researchers and oncologists are familiar with the data's potential and developing the data engineering capacity to utilize this rich data source, will expand the breadth of research to improve cancer care.

Hospitalization rates from radiotherapy complications in the United States

Hospitalizations due to radiotherapy (RT) complications result in significant healthcare expenditures and adversely affect the quality of life of cancer patients. Using a nationally representative dataset, the objective of this study is to identify trends in the incidence of these hospitalizations, their causes, and the resulting financial burden. Data from the National Inpatient Sample was retrospectively analyzed from 2005 to 2016. RT complications were identified using ICD-9 and ICD-10 external cause-of-injury codes. The hospitalization rate was the primary endpoint, with cost and in-hospital death as secondary outcomes. 443,222,223 weighted hospitalizations occurred during the study period, of which 482,525 (0.11%) were attributed to RT. The 3 most common reasons for RT-related hospitalization were cystitis (4.8%, standard error [SE] = 0.09), gastroenteritis/colitis (3.7%, SE = 0.07), and esophagitis (3.5%, SE = 0.07). Aspiration pneumonitis (1.4-fold) and mucositis (1.3-fold) had the highest relative increases among these hospitalizations from 2005 to 2016, while esophagitis (0.58-fold) and disorders of the rectum and anus were the lowest (0.67-fold). The median length of stay of patient for hospitalization for RT complications was 4.1 (IQR, 2.2-7.5) days and the median charge per patient was $10,097 (IQR, 5755-18,891) and the total cost during the study period was $4.9 billion. Hospitalization for RT-related complications is relatively rare, but those that are admitted incur a substantial cost. Use of advanced RT techniques should be employed whenever possible to mitigate the risk of severe toxicity and therefore reduce the need to admit patients.

Predictive Modeling for Adverse Events and Risk Stratification Programs for People Receiving Cancer Treatment

Emergency department visits and hospitalizations are common among people receiving cancer treatment, accounting for a large proportion of spending in oncology care and negatively affecting quality of life. As oncology care shifts toward value- and quality-based payment models, there is a need to develop interventions that can prevent these costly and low-value events among people receiving cancer treatment. Risk stratification programs have the potential to address this need and optimally would consist of three components: (1) a risk stratification algorithm that accurately identifies patients with modifiable risk(s), (2) intervention(s) that successfully reduce this risk, and (3) the ability to implement the risk algorithm and intervention(s) in an adaptable and sustainable way. Predictive modeling is a common method of risk stratification, and although a number of predictive models have been developed for use in oncology care, they have rarely been tested alongside corresponding interventions or developed with implementation in clinical practice as an explicit consideration. In this article, we review the available published predictive models for treatment-related toxicity or acute care events among people receiving cancer treatment and highlight challenges faced when attempting to use these models in practice. To move the field of risk-stratified oncology care forward, we argue that it is critical to evaluate predictive models alongside targeted interventions that address modifiable risks and to demonstrate that these two key components can be implemented within clinical practice to avoid unplanned acute care events among people receiving cancer treatment.

Referral Patterns of Outpatient Palliative Care among the Head and Neck Cancer Population

Introduction Patients with head and neck cancer (HNC) experience unique physical and psychosocial challenges that impact their health and quality of life. Early implementation of palliative care has been shown to improve various health care outcomes.

Objective The aim of the present study was to evaluate the patterns of referral of patients with HNC to outpatient palliative care as they relate to utilization of resources and end-of-life discussions.

Methods We performed a retrospective review of 245 patients with HNC referred to outpatient palliative care services at two Louisiana tertiary care centers from June 1, 2014, to October 1, 2019. The control group consisted of those that were referred but did not follow-up. Reasons for referral were obtained, and outcome measures such as emergency department (ED) visits, hospital readmissions, and advance care planning (ACP) documentation were assessed according to predictive variables.

Results There were 177 patients in the treatment group and 68 in the control group. Patients were more likely to follow up to outpatient palliative care services if referred for pain management. Hospital system, prior inpatient palliative care, and number of outpatient visits were associated with an increased likelihood for ED visits and hospital readmissions. Those in the palliative care treatment group were also more likely to have ACP discussions.

Conclusion Early implementation of outpatient palliative care among patients with HNC can initiate ACP discussions. However, there are discrepancies in referral reasons to palliative care and continued existing barriers to its effective utilization.

Gut Microbiota-Derived PGF2α Fights against Radiation-Induced Lung Toxicity through the MAPK/NF-κB Pathway

Radiation pneumonia is a common and intractable side effect associated with radiotherapy for chest cancer and involves oxidative stress damage and inflammation, prematurely halting the remedy and reducing the life quality of patients. However, the therapeutic options for the complication have yielded disappointing results in clinical application. Here, we report an effective avenue for fighting against radiation pneumonia. Faecal microbiota transplantation (FMT) reduced radiation pneumonia, scavenged oxidative stress and improved lung function in mouse models. Local chest irradiation shifted the gut bacterial taxonomic proportions, which were preserved by FMT. The level of gut microbiota-derived PGF2α decreased following irradiation but increased after FMT. Experimental mice with PGF2α replenishment, via an oral route, exhibited accumulated PGF2α in faecal pellets, peripheral blood and lung tissues, resulting in the attenuation of inflammatory status of the lung and amelioration of lung respiratory function following local chest irradiation. PGF2α activated the FP/MAPK/NF-κB axis to promote cell proliferation and inhibit apoptosis with radiation challenge; silencing MAPK attenuated the protective effect of PGF2α on radiation-challenged lung cells. Together, our findings pave the way for the clinical treatment of radiotherapy-associated complications and underpin PGF2α as a gut microbiota-produced metabolite.

Perceptions of the Cardiologists and Oncologists: Initial Step for Establishing Cardio-Oncology Service

Background: Over the last years, there was no established cardio-oncology service in Iraq and no firm data about the incidence of cardiovascular disease (CVD) among patients with cancer. As an initial step, we decided to conduct a national cardio-oncology online survey for cardiologists, oncologists, and their residents which would help us to understand the expected prevalence, problems, and readiness for collaboration between the two specialties.

Objectives: For evaluating the current national practice in the cardiology and oncology specialty fields and to identify the hidden gaps associated with the development or worsening of CVD among patients with cancer.

Methods: An online survey including 19-question for cardiologists/cardiology residents (CCRs) and 30-question for oncologists/oncology residents (OORs) about cardio-oncology service was sent to them including all Iraqi cities using Google document form during December 2020.

Results: The total number of responses was 164, mainly 62.2% from CCRs while 37.8% from OORs. Hypertension was the main baseline risk factor (71%). A 77.5% of CCRs prescribe cardiovascular drugs vs. 35.5% by OORs. About 76.5% of CCRs and 79% of OORs are facing difficulties in the management of patients with cancer with established CVD. CVD was the leading cause of both hospitalization (30.7%) and mortality (48.4%). About 62.8% of CCRs and 64.5% of OORs have an interest to work in cardio-oncology service.

Conclusion: Based on the perception of cardiologists and oncologists, CVD is the main cause of hospitalization and mortality among patients with cancer. High interest among CCRs and OORs to work in cardio-oncology service. Positive initiatives are available to take the action plan in this emerging field.

Low-Intensity Exercise Modulates Gut Microbiota to Fight Against Radiation-Induced Gut Toxicity in Mouse Models

Radiation-induced gastrointestinal (GI) tract toxicity halts radiotherapy and degrades the prognosis of cancer patients. Physical activity defined as “any bodily movement produced by skeletal muscle that requires energy expenditure” is a beneficial lifestyle modification for health. Here, we investigate whether walking, a low-intensity form of exercise, could alleviate intestinal radiation injury. Short-term (15 days) walking protected against radiation-induced GI tract toxicity in both male and female mice, as judged by longer colons, denser intestinal villi, more goblet cells, and lower expression of inflammation-related genes in the small intestines. High-throughput sequencing and untargeted metabolomics analysis showed that walking restructured the gut microbiota configuration, such as elevated Akkermansia muciniphila, and reprogramed the gut metabolome of irradiated mice. Deletion of gut flora erased the radioprotection of walking, and the abdomen local irradiated recipients who received fecal microbiome from donors with walking treatment exhibited milder intestinal toxicity. Oral gavage of A. muciniphila mitigated the radiation-induced GI tract injury. Importantly, walking did not change the tumor growth after radiotherapy. Together, our findings provide novel insights into walking and underpin that walking is a safe and effective form to protect against GI syndrome of patients with radiotherapy without financial burden in a preclinical setting.

Effect of Radiotherapy and Low-Level Laser Therapy on Circulating Blood Cells of Rats

Introduction: This study aimed to investigate the effect of low-level laser therapy (LLLT) on the blood cell count when applied to parotid glands of rats irradiated by volumetric modular arc therapy (VMAT). Methods: Thirty-two adult male Wistar rats were used in this study. Samples were randomly assigned to three groups: control group (CG, n = 8), immediate laser group (24 hours) (ILG, n=12), and late laser group (120 hours) (LLG, n=12). The two laser groups were previously subjected to VMAT radiotherapy in a single dose of 12 Gy. LLLT with an AsGaAl laser (660 nm, 100 mW) was applied at three points in the region of the parotid glands, right side, with the energy of 2 J per point (20s, 70 J/cm²) and a spot size of 0.0028 cm² for 10 consecutive days. In the euthanasia, blood samples were obtained by cardiac puncture. The samples from each group were processed by an automatic method and analyzed for erythrogram, leukogram and platelet count values. The data were analyzed by ANOVA and each LLLT time point was analyzed in relation to the control group, with a significance level less than 0.05. Results: Groups using LLLT had higher red blood cell counts, being higher in the LLG (P = 0.000). The hematimetric indices MCV (P = 0.002) and MCH (P = 0.009) were lower than the control group, especially when compared to the group using LLLT 120h after radiotherapy (LLG). White blood cell counts were lower in the groups with radiotherapy and immediate use of LLLT (ILG) (P = 0.011), mainly at the expense of lymphocytes (P = 0.002). Conclusion: The results suggest a potential systemic effect of LLLT, especially on circulating red blood cell counts, regardless of their time of immediate or late use of radiotherapy.